by Robin Cook
“Was it easier when you got to college?”
“In some ways yes and some ways no. He was disgusted with me, and instead of calling me a ‘candy ass,’ I became a ‘highfalutin ass.’ He was embarrassed to talk about me to his friends. The biggest problem was that he refused to fill out the financial forms necessary to apply for a scholarship and, of course, refused to contribute a cent.”
“How were you able to pay for college?”
“I relied on a combination of loans, scholastic awards, and every type of job I could manage to get and still keep a four-point-oh grade point average. The first couple of years it was mostly restaurant work, washing dishes and waiting tables. During the last two I was able to work in a variety of science labs. During summers I worked in the hospital at any job they would give me. Also, my brother helped me a little, although he couldn’t do much, since he’d already started a family.”
“Did your goal of medicine and your desire to help people support you during these difficult years?”
“Absolutely, especially the summer work in the hospital. I worshipped the doctors and the nurses, particularly the residents. I could not wait to become one of them.”
“What happened when you got to medical school? Were your financial difficulties worse or less severe?”
“Much worse. The expenses were greater and the curriculum required more hours, essentially all day every day in contrast to college.”
“How did you manage?”
“I borrowed as much as I was allowed; the rest I had to earn with a myriad of jobs all around the medical center. Luckily, jobs abounded.”
“How did you find the time? Medical school is considered a full-time occupation and then some.”
“I went without sleep. Well, not totally, since that is physically impossible. I learned to sleep in short snatches even during the day. It was difficult, but at least in medical school the goal was in sight, which made it easier to endure.”
“What kind of jobs did you do?”
“All the usual medical center jobs like drawing blood, type- and cross-matching blood, cleaning animal cages—anything and everything that could be done at night. I even worked in the medical center kitchen. Then, during the second year, I landed a terrific job with a researcher studying sodium ion channels in nerve and muscle cells. I’ve even kept up that work today.”
“With such a busy schedule in medical school, how were your grades?”
“Excellent. I was in the top ten percent of my class and a member of the Alpha Omega Alpha honorary scholastic society.”
“What do you consider your biggest sacrifice? Was it the chronic lack of sleep?”
“No! It was the lack of any time for social contact. My classmates had time to interact and discuss the experience. Medical school is quite intense. During my third year, I was conflicted about whether to go into academic/basic-science medicine or clinical medicine. I would have loved to debate the pros and cons and have the benefit of others’ opinions. I had to make the decision myself.”
“And how did you make the decision?”
“I realized I liked taking care of people. There was an immediate gratification that I savored.”
“So it was the contact with individuals that you found enjoyable and rewarding.”
“Yes, and the challenge of coming up with the differential diagnoses, as well as the paradigm for narrowing the field.”
“But it was the contact with the people and helping them that you cherished.”
“Objection,” Tony said. He had been progressively fidgeting. “Repetitious.”
“Sustained,” Judge Davidson said with a tired voice. “No need to belabor the point, Mr. Bingham. I am confident the jury has gotten it.”
“Tell us about your residency training,” Randolph said.
“That was a joy,” Craig said. He was now sitting up straight, with his shoulders back. “Because of my grade point average, I was accepted to train at the prestigious Boston Memorial Hospital. It was a wonderful learning environment, and suddenly I was being paid, not a lot of money, but some. Equally important, I was no longer paying tuition, so I could begin to pay off the shocking debt I’d assumed from college and medical school.”
“Did you continue to enjoy the necessarily close bonds that had to form between you and your patients?”
“Absolutely. That was by far the most rewarding part.”
“Now tell us about your practice. I understand there were some disappointments.”
“Not at first! Initially, my practice was everything I had dreamed it would be. I was busy and stimulated. I enjoyed going in each and every day. My patients were challenging intellectually and appreciative. But then the insurance companies began to withhold payments, often needlessly challenging certain charges, making it progressively difficult to do what was best for my patients. Receipts began to fall while costs continued to rise. In order to keep the doors open, I had to increase productivity, which is a euphemism for seeing more patients per hour. I was able to do this, but as it continued, I became progressively concerned about quality.”
“I understand that your style of practice changed at that point.”
“It changed dramatically. I was approached by an older, revered physician who was practicing concierge medicine but who was having health issues. He offered me a partnership.”
“Excuse me for interrupting,” Randolph said. “Perhaps you could refresh for the jurors the meaning of the term ‘concierge medicine.’ “
“It’s a practice style in which the physician agrees to limit the practice size to offer extraordinary accessibility for an annual retainer fee.”
“Does extraordinary accessibility include house calls?”
“It can. It’s up to the doctor and the patient.”
“What you are saying is that with concierge medicine, the doctor can tailor the service to the needs of the patient. Is that correct?”
“It is. Two fundamental principles of good patient care are the principle of patient welfare and the principle of patient autonomy. Seeing too many patients per hour threatens to violate these principles, since everything is rushed. When the doctor is pressed for time, the interview has to be forced, and when that happens, the patient’s narrative is lost, which is tragic, since it is often within the narrative that the critical facts of the case are hidden. In a concierge practice, like mine, I can vary the time I spend with the patient and the location of the service according to the patient’s needs and wishes.”
“Dr. Bowman, is the practice of medicine an art or a science?”
“It is definitely an art, but it is based on a bedrock of proven science.”
“Can medicine be appropriately practiced from a book?”
“No, it cannot. There are no two people alike in the world. Medicine has to be tailored for each patient individually. Also, books are invariably outdated by the time they come on the market. Medical knowledge is expanding at an exponential rate.”
“Does judgment play a role in the practice of medicine?”
“Absolutely. In every medical decision, judgment is paramount.”
“Was it your medical judgment that Patience Stanhope was best served by your making a visit to her home on the evening of September eighth, 2005.”
“Yes, it was.”
“Can you explain to the jury why your judgment led you to believe this was the best course of action?”
“She detested the hospital. I was even reluctant to send her to the hospital for routine tests. Visits to the hospital inevitably exacerbated her symptoms and general anxiety. She much preferred for me to come to her home, which I had been doing almost once a week for eight months. Each time it had been a false alarm, even on those occasions when I was told by Jordan Stanhope that she believed she was dying. On the evening of September eighth, I was not told she thought she was dying. I was confident the visit would be a false alarm like all the others, yet as a doctor, I could not ignore the possibility she was t
ruly ill. The best way to do that was to go directly to her home.”
“Ms. Rattner testified that you told her en route that you thought her complaints might be legitimate. Is that true?”
“It is true, but I didn’t say that I considered the chances to be extremely small. I said I was concerned because I noted slightly more concern than usual in Mr. Stanhope’s voice.”
“Did you tell Mr. Stanhope on the phone that you believed Mrs. Stanhope had had a heart attack?”
“No, I did not. I told him that it would have to be ruled out with any complaint of chest pain, but Mrs. Stanhope had had chest pain in the past that had proved to be insignificant.”
“Did Mrs. Stanhope have a heart condition?”
“I had done a stress test previous to her demise that was equivocal. It wasn’t enough to say she had a heart condition, but I felt strongly that she should have more definitive cardiac studies by a cardiologist at the hospital.”
“Did you recommend that to the patient?”
“I strongly recommended it, but she refused, particularly since it involved going to the hospital.”
“One last question, doctor,” Randolph said. “In relation to your office’s PP, or problem patient, designation, did that signify the patient got more attention or less attention?”
“Considerably more attention! The problem with patients so designated was that I could not relieve their symptoms, whether real or imagined. As a doctor, I found that a continual problem, hence the terminology.”
“Thank you, doctor,” Randolph said as he gathered up his notes. “No more questions.”
“Mr. Fasano,” Judge Davidson called. “Do you wish to redirect?”
“Absolutely, Your Honor,” Tony barked. He jumped to his feet and rushed to the podium like a hound after a rabbit.
“Dr. Bowman, in relation to your PP patients, did you not say to your then live-in girlfriend while riding in your new red Porsche on the way to the Stanhope home on September eighth, 2005, that you couldn’t stand such patients and that you thought hypochondriacs were as bad as malingerers?”
There was a pause as Craig fixed Tony with his eyes as if they were weapons.
“Doctor?” Tony asked. “Cat got your tongue, as we used to say in elementary school?”
“I don’t remember,” Craig said finally.
“Don’t remember?” Tony questioned with exaggerated disbelief. “Oh, please, doctor, that’s a too convenient excuse, especially from someone who has excelled throughout his training at remembering trivial details. Ms. Rattner certainly remembered as she testified. Perhaps you can remember telling Ms. Rattner on the evening you were served your summons for this lawsuit that you hated Patience Stanhope and that her passing was a blessing for everyone. Is that possibly something you can recall?” Tony leaned forward over the podium as much as his short stature would allow and raised his eyebrows questioningly.
“I said something to that effect,” Craig reluctantly admitted. “I was angry.”
“Of course you were angry,” Tony exclaimed. “You were outraged that someone, like my bereaved client, could possibly have the gall to question whether your judgment was in keeping with the standard of care.”
“Objection!” Randolph said. “Argumentative!”
“Sustained,” Judge Davidson said. He glared at Tony.
“We are all impressed with your rags-to-riches story,” Tony said, maintaining his disdain. “But I’m not sure what that means now, especially considering the lifestyle your patients have provided you over the years. What is the current market value of your home?”
“Objection,” Randolph said. “Irrelevant and immaterial.”
“Your Honor,” Tony complained. “The defense presented economic testimony to attest to the defendant’s commitment to become a physician. It is only reasonable for the jury to hear what economic rewards have accrued.”
Judge Davidson pondered for a moment before saying, “Objection overruled. The witness may answer the question.”
Tony redirected his attention at Craig. “Well?”
Craig shrugged. “Two or three million, but we didn’t pay that.”
“I would now like to ask you a few questions about your concierge practice,” Tony said, gripping the sides of the podium tightly. “Do you believe that demanding an annual, up-front payment of thousands of dollars is beyond some patients’ means?”
“Of course,” Craig snapped.
“What happened to those beloved patients of yours who either could not or did not for whatever reason come up with the retainer fee that was financing your new Porsche and your sex den on Beacon Hill?”
“Objection!” Randolph said. He stood up. “Argumentative and prejudicial.”
“Sustained,” Judge Davidson barked. “Counsel will restrict his questions to elicit appropriate factual information and will not word his questions to float theories or arguments better left for summation. This is my last warning!”
“I’m sorry, Your Honor,” Tony said before turning back to Craig. “What happened to those beloved patients whom you had been caring for over the years?”
“They had to find new doctors.”
“Which I’m afraid is often easier said than done. Did you help with this chore?”
“We offered names and numbers.”
“Did you just get them out of the Yellow Pages?”
“They were local physicians, with whom my staff and I were acquainted.”
“Did you call these physicians?”
“In some cases.”
“Which means in some cases you did not call. Dr. Bowman, did it not bother you to abandon your supposedly cherished patients who were desperate, looking to you for their health needs?”
“I didn’t abandon them!” Craig spat indignantly. “I gave them choices.”
“No more questions,” Tony said. He rolled his eyes on the way back to the plaintiff’s table.
Judge Davidson looked over his glasses at Randolph. “Does the defense wish to recross?”
“No, Your Honor,” Randolph said, half rising out of his chair.
“The witness may step down,” Judge Davidson said.
Craig stood and, with a deliberate step, walked back to the defense table.
The judge turned his attention to Tony. “Mr. Fasano?”
Tony stood. “Plaintiff rests, Your Honor,” he said confidently before retaking his seat.
The judge’s eyes swept back to Randolph.
On cue, Randolph stood up to his full patrician height. “Based on the inadequacy of the plaintiff’s case and lack of evidence thereof, the defense moves to dismiss.”
“Overruled,” Judge Davidson said crisply. “The evidence presented is sufficient for us to go forward. When court reconvenes after a lunch break, you may call your first witness, Mr. Bingham.” He then brought his gavel down sharply, and the sound echoed like a gunshot. “Recess for lunch. You are admonished again not to discuss the case among yourselves or with anyone and to withhold any opinions until the conclusion of the testimony.”
“All rise,” the court officer called out.
Jack and Alexis got to their feet along with everyone else in the courtroom as the judge stepped down from the bench and disappeared through the paneled side door.
“What did you think?” Jack asked while the jury was ushered out.
“I’m continually amazed at the level of Craig’s apparent inner anger at these proceedings, that he has such little self-control over his behavior.”
“With you being the in-house expert, I’m surprised you’re surprised. Isn’t it consistent with his narcissism?”
“It is, but I was hoping that with the insight he expressed yesterday at lunch, he’d be able to control himself better. When Tony merely stood up even before he started his questions, I could see Craig’s expression change.”
“Actually, I was asking your opinion of how Randolph orchestrated the part of the cross-examination we heard.”
“Unfortunately, I don’t think it was as effective as I would have hoped. It made Craig sound too preachy, like he was giving a lecture. I would have preferred the whole cross to have been punchy and direct, like it was at the end.”
“I thought Randolph’s cross was pretty effective,” Jack said. “I never realized Craig was such a self-made man. Working as hard as he did at gainful employment while going to medical school and still getting the grades he did is very impressive.”
“But you’re a doctor, not a juror, and you didn’t hear Tony’s direct. Craig might have struggled as a student, but from the juror’s perspective, it’s hard to have sympathy now that Craig and I are living in what is probably closer to being a four-million-dollar home, and Tony was very clever on his redirect, the way he brought back Craig’s negative feelings about the patient, the red Porsche, the girlfriend, and the fact that he had to forsake many of his old patients.”
Jack reluctantly nodded. He had been struggling to look on the bright side for Alexis’s benefit. He tried a different tack: “Well, now it’s Randolph’s turn in the sun. It’s time for the defense to shine.”
“I’m afraid there’s not going to be much sunshine. All Randolph is going to do is present two or three expert witnesses, none of whom are from Boston. He said he’ll be finished this afternoon. Tomorrow will be the summations.” Alexis shook her head dejectedly. “Under the circumstances, I don’t see how he could turn this thing around.”
“He’s an experienced malpractice attorney,” Jack said, attempting to generate enthusiasm he didn’t feel. “Experience generally prevails in the final analysis. Who knows. Maybe he has a surprise up his sleeve.”
Jack didn’t realize he was half-right. There was to be a surprise, but it wasn’t going to come from Randolph’s sleeve.
18
BOSTON, MASSACHUSETTS
Thursday, June 8, 2006
1:15 p.m.